Can chronic pain treatment benefit from a public health perspective?

This is a bonus addition to a series exploring the intersections between effectively caring for people living with chronic pain and the rise in unintentional poisoning deaths due to prescription painkillers. To read the three-part series, which explores the science of pain management as well as physicians' and public health workers' roles in preventing opioid abuse and overdose, click here, here and here.

by Kim Krisberg

"If you really look at how pain affects people and what it means to have start to view it more as a social phenomenon."

These are words from Dr. Daniel Carr, a professor of public health, anesthesiology, medicine and molecular physiology and pharmacology at Tufts University. He also directs and co-founded the university's Pain Research, Education and Policy Program, the only such pain program housed within a school of public health. I had called Carr to discuss the role of public health workers in addressing today's worrisome prescription drug abuse and unintentional poisoning rate — a trend largely driven and connected to prescription opioids. But in true public health fashion, Carr took the conversation back to the beginning. The time for a population-based approach doesn't begin with misuse and abuse, he said; it begins, in fact, with how we interpret the contributors to pain in the first place.

Carr told the story of a chronic pain patient he once treated who said she'd gone from "big pain, small life to small pain, big life." In other words, as her pain shrank, it created room for the rest of her life to flow back in and allowed her to re-engage in the social, vocational and educational networks that we all use to define ourselves. Carr said he believes that chronic pain is inherently linked to isolation and stigmatization, factors that become clearer if viewed through a public health-inspired, population health-based lens.

For example, he asked: What's one of the most commonly used and safest analgesics? Answer: The safe embrace and kiss from mother to toddler — "it addresses feelings of distress and isolation that in individuals with pain are triggered almost instantly," Carr said. In a 2009 article he wrote for a publication of the International Association for the Study of Pain (IASP), he discussed the interplay of social and biological, referencing the patient above:

"The warning signal of acute pain is one of many processes that nature has given us to help convey our species' genetic material across generations. If despite such warning we are hurt, nature provides us with temporary endogenous analgesia to help us escape further harm. Once we successfully escape further acute injury, our bodies draw upon an integrated repertoire of restorative processes that nature has also provided. But if despite these resources we fail to reclaim our place in society, nature liquidates her accumulated investment in our individual wellbeing. For the patient (above), losing her everyday social, family and vocational interactions meant losing what defined her life."

Carr noted that research examining the parts of our brains that respond to pain strongly shows that pain is very much a social process. And if that's the case, then it seems only logical that clinicians and their patients would benefit greatly from expanding their frames of reference and taking a cue from public health — "otherwise, we wind up leaving (clinicians) taking care of patients thinking that if they could just work the pharmacology better, things would improve. But that's an illusion," Carr said.

"This does not negate the truth at the micro level, but instead the frame of reference is shifted so that the questions it poses and the answers it seeks include the interactions between individuals," he said. "I would never say that pain is not real...I'm just talking about how we should interpret and study it."

Regarding the startling rise in opioid-related abuse and death, Carr, who treated patients for 20 years, noted that no one who was initially advocating for expanding treatment options "anticipated there would be this epidemic of misuse and abuse." However, after talking with Carr, it seems that integrating public health perspectives into pain care could shift prescribing practices and eventually affect the flow of prescription painkillers into the illicit market.

Carr writes in the IASP article: "I cannot think of a better subject than pain as a means to link objective measurement with existential experience, nor a more rewarding way to spend one's time than in helping pain sufferers."

To learn more, visit Tufts' Pain Research, Education and Policy Program and its blog, PREP-Aired.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.


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What makes me crazy in this conversation is that the legit patients -- those with long-term, chronic pain who are *not* gaming the system, doctor-shopping, getting high from, or selling their meds -- are the ones who pay the price for the drug-seekers.

I'm thinking specifically of the amount of healthcare dollars spent on my monthly medication management -- which includes a urine test and appointment, and quarterly check-ins with a psychologist. (My opiate dose hasn't changed in five years, and use a number of non-opiate options as well). All this to appease the Feds because of those breaking the law.

So should we not address the drug-seekers and those who sell and buy diverted opiate medications, instead of those legit patients?

I'm tired of being treated like a junkie when I'm the one following the rules!

By OleanderTea (not verified) on 05 Dec 2012 #permalink

So Oleander, all those measures you complain about are designed to separate those who "deserve" narcotics" (in your term the "legit" narcotic seekers) from those who seek them but do not "deserve" them. Since 100% of people seeking narcotics describe themselves like you, what suggestion do you have for doctors trying to separate the "deserving" from the "undeserving"? One response is to try to use tests and rules. Another response is to refuse to try and to write prescriptions for all seekers--- the doctor will attract attention from the DEA real fast doing that. The third response is to refuse to prescribe for anyone-- what feels to you like considering all pain patients are junkies.

How many people who seek narcotics as the best treatment for pain are open to non-narcotic alternatives?

By john smith (not verified) on 05 Dec 2012 #permalink

Perhaps the conclusion was less than clear. It should have said:

One strategy for doctors is to try to separate the "deserving" from the "undeserving" by the rules and tests and strict procedures you complain about. A second response is to refuse to discriminate and write narcotics for anyone who says they need it--- and the doctor who does that will attract the attention of the DEA real fast. A third response is to refuse to prescribe narcotics for anyone-- the very response that feels to you like "being treated like a junkie".

How many people who seek narcotics for their pain are open to non-narcotic treatments?

By john smith (not verified) on 05 Dec 2012 #permalink

I suffer chronic pain. Codeine (when needed and in as small of a dose as possible) is the difference between a decent functional life (I can't work due to these health issues) or pain, misery and inability to function.

More and more it's harder to get as doctors are afraid of the Feds and the Feds think we're all supporting cartels or something.

I have nothing but resentment for our country, who treats us like babies and assumes we're all dope fiends. And ironically, while pain meds HAVE a real use other than getting high, stuff like cigs and alcohol have ZERO use other than recreational use yet they are legal.

If people want to kill themselves, let them. But get them out of the way of people who genuinely need pain pills (or Sudafed for a cold or whatever).

The War on Drugs should end. We lost it when it began, and should have taken a lesson from Prohibition. Other civilized countries aren't this stupid. They make certain meds available - behind the counter to keep the kiddies from getting them. Why can't we treat our citizens as adults, not potential drug fiend felons?

What non-narcotic suggestions do you have?

I'm going to just ignore john smith's provocative and unkind response to Oleander Tea — its very tone underscores Oleander Tea's point.

With regard to the subject of this bonus post — speaking from sorry personal experience, its premise is very, very true. But it's true about illness and disability in general. Illness, disability, and pain are isolating and work toward divorcing sufferers from the greater life milieu which has a substantial health benefit.

My illness makes me less mobile directly, and the associated chronic pain both directly and indirectly. It is difficult to leave the house in all respects — it requires effort, both physical and emotional. And something that I think no one who's suffered chronic pain understands is that the pain itself is not so directly disabling — because chronic pain is not subjectively experienced like acute pain; to some degree it can be and must be ignored — but, rather, it's extremely indirectly disabling. It's exhausting. It's like some constant drain on all vitality, both physical and emotional.

And so in addition the the primary disability that impedes mobility, there's this secondary disability impeding mobility due to chronic pain. Collectively and cumulatively, it's increasingly isolating. In turn, all the things that make a life worth living, that make it worth it to rise above illness and disability, seem to fade away. It's a vicious cycle and it's terribly important that it be disrupted.

But good luck on that. For the most part, successful intervention in this and with illness management in general requires a lot of self-motivation and self-direction by the patient. And when the illness attacks those things directly, then there's a problem.

By Keith M Ellis (not verified) on 05 Dec 2012 #permalink

The original post was on an important topic. The response by Oleander was a perfect description of one perspective on the problem-- that of the sufferer. I provided a second perspective on the problem-- that of the doctor. The intention was not unkindness but to provide the counterpart that shows how awful the problem seems from both perspectives.

Doctors would truly welcome a non-narcotic response to chronic pain. Both of you represent the plight of the chronic pain sufferer but dodge the point of this article--- a response to pain that does not involve narcotics. What do you think of this article and that alternative approach?

By john smith (not verified) on 06 Dec 2012 #permalink

Well, john, I'm one who's happily receiving non-narcotic treatments as well.

And I see an office full of people receiving non-narcotic treatments as well as various medications every time I go visit my pain management team's office. At a proper pain clinic -- as opposed to a pill mill, which I stumbled into years ago -- one is encouraged to get non-narcotic treatment., and sometimes that is part of the contract one signs.

Which is fine by me. Part of why my med dose has been so stable is due to the intervention of nerve blocks in my head and neck, Botox for chronic migraine, joint injections, and epidural injections for spinal stenosis. (That's a lot of needles now that I list it out. I'm a pincushion!)

There is, of course, also an issue of health care dollars and availablity here. Many people with, say, back injuries are not in a financial or insurance position to make the committment to PT and epidurals and nerve blocks. They have to go back to work or risk losing income or a job. So they take pills to cope with the pain and the work. Maybe some of our problems with diversion and overuse are due to problems outside of both the doctor's and patient's control.

By OleanderTea (not verified) on 06 Dec 2012 #permalink

I dont dispute anything you or Keith Ellis wrote. It's a messy problem with contributions way outside of those under the control of patients and doctors. I have seen someone close experience all the problems both of you describe.

There is no question that from a public health perspective it is huge. I am curious about Carr's specific recommendations but the link in the article above does not work for me.

By john smith (not verified) on 06 Dec 2012 #permalink

I'm very open to pain relief without narcotics (I take as low as dose as I can when it comes to my own usage) as I don't like the feeling that a narcotic gives; I just want relief.

Problem is, how do I realistically get that relief without narcotics? I've seen enough snake oil salesmen and "think it away" morons to last a lifetime.

My conditions (degenerative disc disease and both OA and RA) aren't going away. At best, I can keep them stabilized. I've used physical therapy when necessary.

There is no real answer, so far, none that I see. The meds are the difference between functioning reasonably pain free (when I'm in flare or have a herniated disc) or being in agony.

I won't do spine shots. I have a phobia about putting needles in my spine (paralysis fear) to the point of having all 3 of my kids with no pain meds. So you see, it's not as if I'm a sissy! *lol*

Bonnie M, you can have "spine shots" with sedation. I don't have a phobia, but don't care to know when the doctor is sticking needles into my spine. It feels very odd.

But oh, the relief is worth it.

Other options -- hot and cold packs, topical NSAIDs, nerve ablation perhaps. They are out there.

I find massage helpful and am lucky enough to be able to use my healthcare flex spending account to pay for it.

So there's stuff out there, though I agree you have to be mindful of avoiding the snake oil salesmen.

I can't get "the same" relief as from narcotics -- but even being able to reduce one's dose is nice.

By OleanderTea (not verified) on 07 Dec 2012 #permalink

There's not much out there. Not truly. If the pain is tolerable (and I can tolerate a lot), I either ignore it or take a hot bath (I prefer heat). If it's really bad - meds.

With the spinal phobia, it would have to be a super emergency (like a spinal tap for some grave condition) to ever get me to get a needle in the spine. Normally, shots are no big deal - except in the spine.

Massage is helpful for the fibro, but nothing fixes degenerating discs. All one can do is do proper exercise to keep 'em in place, and if the pain is excruciating/never-ending, do the fusion which to me seems to cause problems as often as it solves them, which is why I declined it some time back.

I'm used to what I have. The world isn't going to end if I take 2 codeine 1's a day for pain when necessary. If that makes me addicted, then cue Rhett Butler. ;)

I only know that as soon as they stopped the excess and almost all dispensing of oxycodone due to the tremendous rise in sales, it didn't change a thing, the drug seekers started overdosing on the opiates that the doctors prescribed in place of oxycodone. Plus there was a huge rise in heroin deaths that had previously been much lower. I understand stopping pill mills but the DEA taking such extremes as not allowing a legitimate patient that has been on pain meds for 15 years plus to not be able to pay cash for the script is rediculous. I am changing my prescription plan in Jan, 2013 and the mail order place did not take my present plan, I sent them a check to pay for the pain meds and they called and said the DEA will not let customers pay cash for narcotic pain meds. So i am without till January.
There is proof that I am legit but still I get treated like a junkie, not on purpose but still I'm run thru the mill. That's what we're all talking about. Crap like that.!

By Debbie Duke (not verified) on 07 Dec 2012 #permalink

We have had reports of many people who suffer from chronic pain get relief with Neurofeedback.Neurofeedback would address different root causes for the pain. For example, in research there is a link between poor sleep and fibromyalgia. Neurofeedback trains the brain to have better sleep patterns and then the symptoms from fibromyalgia begin to dissipate. There is a similar phenomenon when the root cause of pain stems from PTSD. Neurofeedback addresses the PTSD and the "side effect" (in this case a positive side effect) is that the chronic pain diminishes.

By Neurofeedback (not verified) on 08 Dec 2012 #permalink

It is really bad in GA , I have been in a bank robbery and was injured. The doctors all see that I am suffering and they choose not to give me narcotics. They have me on granadilla and gabepentin aka neuron tin. I still don't have a diagnosis and they won't tell me anything . I have ha 4 MRI last year and two spinal taps and still nothing. I am at my wits end because they think I want to get high and I just want to be able to function everyday. Why don't they get it??

By Nichole brown (not verified) on 19 Jan 2013 #permalink

i was told in 2006 that my lower back was curved and the disc where degenerateing and that i had nerve damage on top of strokes, rheuitod arthis, and now seisures. my docter started me on narco's 1 to2 every 4 to 6 hours. he said when thede no longer worked for me i would go to something a little stronger because i would be on these these the rest of my life and someday i would be in a wheel chair. my docter moved and i found a new docter . well the narco's have run yhere limit they want even get rid of a migrine. so his solution is to just take me off them. so now pain mgt. doctors don't me because i am alleric to steriods. so what do i do? any one got any help send to my emai

By susan taylor (not verified) on 07 Mar 2013 #permalink